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Obsessive-compulsive disorder (OCD) may be present with distressing intrusive thoughts, urges, or images. When the content is violent, sexual, religious, or linked to magical thinking, severe OCD can be mistaken for psychosis. We present a 19-year-old man with a six-year history of ego-dystonic intrusive harm-related thoughts and images focused on family members, along with checking, touching, counting, reassurance seeking, religious mental rituals, and sexual obsessions. Symptoms began at age 13 after he read about asthma, and later developed a recurrent fear that his maternal grandmother might develop the illness. He recognized these thoughts and images arising from his own mind, experienced them as distressing and excessive, and used rituals to reduce anxiety. Examination did not elicit hallucinations, externally located perceptions, thought insertion, withdrawal, broadcasting, passivity phenomena, behavioral disorganization, or mood, substance-related, or neurological syndrome. The diagnosis was obsessive-compulsive disorder, International Statistical Classification of Diseases and Related Health Problems10th Revision (ICD-10), F42.2 mixed obsessional thoughts and acts. Fluvoxamine 50-150 mg/day was associated with a subjective 10%-20% improvement without documented adverse effects; the treatment was later switched to fluoxetine because of cost-related factors. Long-term follow-up and standardized severity scores were unavailable. This case highlights the importance of assessing thought ownership, resistance, insight, conviction, and the anxiety-reducing function of rituals before labeling vivid intrusive mental images as hallucinations or delusions.